Blood Management And Advanced Techniques In Tka Syllabus
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1/14/2013
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1 | MDT Confidential
The Effect of a Comprehensive Blood
Management Protocol on Decreasing
Transfusion Rates Following Primary
Total Joint Arthroplasty
Charles A. Hope, II, MD1, Robert W. Eberle2 ,
Constance B. Squibb, RN, BSN, MPA2
(1) Optim Orthopedics, Savannah, GA
(2) Medtronic Advanced Energy, LLC, Portsmouth, NH
Presented at the AABB Annual Meeting and CTTXPO 2012
October 6-9, 2012, Boston, MA
2 | MDT Confidential
Disclosures
•Stryker
–Consultant and Speaker on Hip and Knee Arthroplasty
surgical techniques and instrumentation.
•Medtronic Advanced Energy
–Consultant and Speaker
AABB Annual Meeting
October 6-9, 2012, Boston, MA
Blood Management Protocol
Hope, et al.
3 | MDT Confidential
INTRODUCTION
•Primary total joint arthroplasty (TJA) is generally
an elective procedure and is associated with
significant blood loss.
•Considerable variations exists in transfusion
practices and in strategies for the management of
blood loss from primary TJA which include;
–Pre-donation of autologous blood
–Salvage and re-infusion of intraoperative and post-
operative shed blood
–The pre-operative use of erythropoietin for the stimulation
of red blood cell production and volume.
AABB Annual Meeting
October 6-9, 2012, Boston, MA
Blood Management Protocol
Hope, et al.
1/14/2013
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4 | MDT Confidential
5 | MDT Confidential
6 | MDT Confidential
Landscape is Changing …
•Medicare no longer paying for the first three units
of blood product
•Headlines are stating,
“Hospitals are Overspending on Blood
Transfusions”
October 9, 2012 Health Leaders Media
•One report estimates that $65 M could be saved if
readmission after hip and knee replacement were
avoided
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7 | MDT Confidential
PURPOSE
•The purpose of our study was
to evaluate the influence of a
comprehensive surgical and
clinical blood management
protocol on the post-operative
transfusion rate in patients
undergoing primary TJA.
Blood Management Protocol
Hope, et al. AABB Annual Meeting
October 6-9, 2012, Boston, MA
8 | MDT Confidential
MATERIALS AND METHODS
•Study
–Prospective, continuous series
–505 primary TJA procedures
–Intra- and peri-operative blood management protocol
•Control
–Retrospective continuous series
–1,092 control primary TJA procedures
–Performed prior to blood management protocol implementation
•Single surgeon
–Similar MIS/Tissue Sparing surgical techniques and TJR
implants
Blood Management Protocol
Hope, et al. AABB Annual Meeting
October 6-9, 2012, Boston, MA
9 | MDT Confidential
MATERIALS AND METHODS
Blood Management Protocol
Hope, et al.
Pre-Operative Blood Management Protocol
AABB Annual Meeting
October 6-9, 2012, Boston, MA
1/14/2013
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10 | MDT Confidential
MATERIALS AND METHODS
Blood Management Protocol
Hope, et al.
Initial Screening
AABB Annual Meeting
October 6-9, 2012, Boston, MA
11 | MDT Confidential
MATERIALS AND METHODS
Blood Management Protocol
Hope, et al.
Hgb < 13 g/dl and inadequate Iron Levels
AABB Annual Meeting
October 6-9, 2012, Boston, MA
12 | MDT Confidential
MATERIALS AND METHODS
Blood Management Protocol
Hope, et al.
Hgb < 13 g/dl and adequate Iron Levels
AABB Annual Meeting
October 6-9, 2012, Boston, MA
1/14/2013
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13 | MDT Confidential
MATERIALS AND METHODS
Blood Management Protocol
Hope, et al.
Hgb> 13 g/dl and adequate iron levels
and can tolerate oral iron
AABB Annual Meeting
October 6-9, 2012, Boston, MA
14 | MDT Confidential
MATERIALS AND METHODS
Blood Management Protocol
Hope, et al.
Intra-Operative
•For the study group, the intra-operative
blood management protocol utilized the
Aquamantys® (AQM) bipolar sealing
technology to achieve and maintain
wound hemostasis.
AABB Annual Meeting
October 6-9, 2012, Boston, MA
15 | MDT Confidential
MATERIALS AND METHODS
Blood Management Protocol
Hope, et al.
Intra-Operative
RF energy and
saline are applied
to tissue
Heat induced
shrinkage occurs
Vessels <1mm
may be occluded,
reducing bleeding
The Aquamantys® System with Transcollation technology combines
radiofrequency (RF) energy and saline for haemostatic sealing and
coagulation of soft tissue and bone at the surgical site.
AABB Annual Meeting
October 6-9, 2012, Boston, MA
1/14/2013
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16 | MDT Confidential
RESULTS
Blood Management Protocol
Hope, et al.
•There was no significant difference in demographics
between study groups.
•Of the 505 treatment TJA cases, there were
4 (< 1.0%) cases in which post-operative allogenic
blood transfusion was necessary.
•In the control group (n=1,092), there were 57 (5.3%)
cases requiring allogeneic blood transfusions.
•This proportional difference was statistically
significant (p < 0.0001).
AABB Annual Meeting
October 6-9, 2012, Boston, MA
17 | MDT Confidential
SURGEON RESPONSE
Blood Management Protocol
Hope, et al.
•In subsequent patients
−Post-operative reinfusion drains were eliminated for Total
Knee Arthroplasty.
−The use of cell saver and reinfusion drains were
eliminated in Total Hip Arthroplasty.
AABB Annual Meeting
October 6-9, 2012, Boston, MA
18 | MDT Confidential
CONCLUSIONS
Blood Management Protocol
Hope, et al.
•Our findings show a significant decrease in
allogeneic transfusion rates following primary TJA
when a total intra- and peri-operative blood
management protocol was implemented featuring
pre-operative anemia control and active intra-
operative hemostasis control.
AABB Annual Meeting
October 6-9, 2012, Boston, MA
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19 | MDT Confidential
Blood Management Protocol
Hope, et al.
CONCLUSIONS
Clinical Value Continuum of Combined Protocols
AABB Annual Meeting
October 6-9, 2012, Boston, MA
20 | MDT Confidential
CONCLUSIONS
Blood Management Protocol
Hope, et al.
Covance report; 2008 MedPAR database based on ICD-9-CM Codes for 100% of Medicare beneficiaries.
AABB Annual Meeting
October 6-9, 2012, Boston, MA
21 | MDT Confidential
CONCLUSIONS
Blood Management Protocol
Hope, et al.
•The proposed blood management protocol was
easy to implement and effective within the scope of
our single surgeon study.
•Further study of this blood management protocol
beyond a single surgeon’s experience is warranted.
AABB Annual Meeting
October 6-9, 2012, Boston, MA
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Blood Management Protocol
Hope, et al.
THANK YOU!
AABB Annual Meeting
October 6-9, 2012, Boston, MA
1/15/2013
1
Tourniquetless TKA
H. Del Schutte, Jr., M.D.
Medical Univ. of South Carolina
January 15, 2013
VUMEDI
Disclosure
•Consultant / speaker
•Medtronic
•Stryker
•Depuy
Tourniquet Use
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Tourniquetless tka
•Infection – antibiotic concentration, tissue
oxygen perfusion
•Blood loss
•Vascular Effects
–Arterial damage
•Return to OR
–DVT
•Multi-organ effects
–Pulmonary, hepatic, splenic
•Cognitive function
•Pain
•Muscle function / Rehab
Tourniquet use
•Antibiotic concentration
•SCIP guidelines
–Vancomycin - 1hour
–Ancef - 20 min
Blood loss
•Tka vs Hand surgery
•Transfusion rate
•Wound healing
•Infection
•Rehab
•Hematoma Rate
•Anticoagulants
•Pain
•Decreased rom
•Infection
Picture courtesy Fred Cushner
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Tranfusion in TKA
•6 % - 42% incidence
•$200/unit - $1000 total cost
•LOS .5 to 1 day longer
•Per surgery costs in pts with
transfusions –
•$3000 knees
•$2000 hips
•Medical risks - infection
•Decreased supply
•Increased demand
Picture courtesy Fred Cushner
Tourniquet use
•Blood loss
–Blood loss after tka – effect of tourniquet
release and cpm - Lotke et al JBJS 1991
•Group 1 full tourniquet and splint
•Group 2 full tourniquet and cpm
•Group 3 tourniquet released and splint
–1400cc blood loss
•Group 4 tourniquet released and cpm
–1800 cc blood loss
Hematoma formation
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Minimizing Blood
loss
•Tissue Adhesives
•Tranxemic Acid
•Tourniquet use
•Transcollation®*
Picture courtesy Fred Cushner
*A combination of radiofrequency (RF) and saline that provides hemostatic sealing of soft tissue and bone.
Epinephrine Injection in
TKA
•Injected along
anticipated
arthrotomy site
•Injected into fat pad
Bipolar sealer technology in TKA
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Transcollation Technology in TKAs
* Marulanda GA, et al. Surg Technol Int.
2005;14:281-6.
** Weeden S. EFORT; 2007
Transfusions reduced by
64%**
Blood loss reduced by
30%*
Comparison of Blood loss in Total
Knee Arthroplasty with and
without Tourniquet use: a
retrospective study of 372 patients
Schutte Jr HD, Martin SM, Patrick
M, Barfield W, Kavolous J.,.
Calculated blood loss
•172 TKAs with tourniquet 1,499.8
•113 without tourniquet 1,538.5
•87 w/o tourniquet and with Transcollation 1,368.5
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Transfusion rate
•172 TKAs with tourniquet 29%
•113 without tourniquet 17%
•87 w/o tourniquet and with Transcollation 13%
Drains - $50-250
Tourniquetless TKA – OR time
Patient group OR TIME
172 TKAs with tourniquet 62.7
113 without tourniquet 61.5
87 w/o tourniquet and with Transcollation 55.9
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Tourniquet use
•Arterial damage
•Return to OR
–Missed arterial injury
–Hematomas
Nishiguchia,et al 2005
•PTE was detected in 6 patients (7.0%)
•2 of 5 (40.0%) patients bilateral TKAs w T
•3 of 42 (7.1%)bilateral TKAs w/o T
•1 of 14 (7.1%) unilateral TKA w T
•PTE did not occur in patients who underwent
unilateral TKA without tourniquet.
•median D-Dimer significantly higher in
patients with tourniquet, both in unilateral
TKA ( p=0.003) and in bilateral TKAs
(p=0.004).
Tourniquet use – DVT?
Tourniquet use
•Pulmonary function
•Multi-organ
function
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Tourniquet release
Tourniquet use
•Pulmonary function
–“Tourniquet application within a safe
limit may cause pulmonary gas
exchange impairment several hours
after tourniquet deflation”
Tourniquet use
•Multi-organ function
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Tourniquet use
•Cardiac function
J Int Med Res. 2010 Jul-Aug;38(4):1519-29.
Effect of high-dose vitamin C on oxygen free radical production and
myocardial enzyme after tourniquet ischaemia-reperfusion injury
during bilateral total knee replacement.
Lee JY, Kim CJ, Chung MY.
Tourniquet use
•Cognitive function
Tourniquet use
•Cognitive function
Cognitive dysfunction after tka
Rodriguez et al, Jl. of Arthroplasty 2005
HITS (cerebral emboli) 22 of 37 pts.
Cognitive dysfunction
41% at 1 week
18% at 3 mos.
higher complication rate
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Tourniquet use
•Pain
Tourniquet use
•Pain
•Vandenbussche et al, International Orthopedics
–Prospective randomized study with and without tourniquet
Sig. decreased pain at 6 hours
–Increased flexion at 5 days
•Abdel-Salam, JBJS 77-B
–80 pts. – sig. degcreased pain without tourniquet
•Barwell, JBJS 79-B
–88 pts. Sig. decreased pain with early release
•Worland, Jl of Arthroplasty 1997
–28 bilat knees, sig. decreased pain without tourniquet
Tourniquet use
•Muscle function
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Tourniquet use
•Patellofemoral tracking
–Husted, Jl. of Arthroplasty 2005
•Tourniquet deflation improved
patellar tracking
–Lombardi, JBJS-B 87-B
•Decreased need for lat. release if
tourniquet released
Tourniquet use
•Muscle function
Arthroscopy. 2001 Jul;17(6):603-7.
The effect on leg strength of tourniquet use during anterior
cruciate ligament reconstruction: A prospective randomized
study.
Nicholas SJ, Tyler TF, McHugh MP, Gleim GW.
CONCLUSIONS: Tourniquet use of less than 114 minutes during
ACL reconstruction had no effect on the strength of the lower
extremity after surgery.
Tourniquet Use
•Range of Motion
•Ledin, Aspenberg, and Good. Acta Orthopaedica
2012; 83 (5): 499–503 499
–Randomized RSA study with 50 patients
–Found less postoperative pain and greater range of motion (11°
more) in the non-tourniquet group (p = 0.001 at 2 years).
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Range of Motion
Range of Motion
Tourniquet Use
•Cement Interdigitation
•Ledin, Aspenberg, and Good. Acta Orthopaedica 2012; 83 (5): 499–503
499
–No statistically significant effect on prosthesis migration
•Vertullo CJ. Presented at the Australian Knee Society Annual
Scientific Meeting 2009, Palm Cove; AOA Annual Science Meeting
2010, Adelaide; ISAKOS Meeting 2011, Rio De Janeiro.
–Prospective, randomized trial of 40 patients, quantified cement
penetration in tourniquet and tourniquetless arms.
–Mean cement penetration and standard deviation (SD) were nearly
identical in each group (2.98 mm with SD of 0.82 in the tourniquet group
versus 3.10 with SD of 0.84 in the tourniquetless group).
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Tourniquetless TKA - Rehab
•Our series of 372 patients
Patient group ROM at 8wks
172 TKAs w/ tourniquet 105.4
113 w/o tourniquet 109.5
87 w/o tourniquet and with Transcollation 114.6
CMS - Applicable Conditions
•The FY 2012 final rule addressed the following
applicable readmissions:
1. Acute myocardial infarction
2. Heart failure
3. Pneumonia
Readmission for orthopaedic procedures is NOT
currently covered; this may change…
47 Federal Register Volume 76, Number 87 (Thursday, May 5, 2011)
48
Unplanned Readmissions after TKA
- Poster #20 AAHKS 2012
Consideration
Metric
30 Day Readmission Rate
5.65%
Readmission associated with:
Increased LOS
p < .001
Revision surgery
p < .001
Most common readmitting diagnoses:
Post-op infection
.5% of pts
Unspecified prosthetic complication
.31% of pts
Hematoma
.28% of pts
PE
.22% of pts
Financial Impact:
Avg profit – w/ reimbursement
$5,219
Re-admitted pts – w/ reimbursement
$2,583 less profitable (p=.001)
Net avg loss – w/o reimbursement
$5,326 per episode of care
Derman et al. Risk Factors, Causes, and the Financial Implications of Unplanned Readmissions after TKA. Poster #20, AAHKS 2012.
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Relationship between timing of
TQ release and readmission
Parameter Early-TQ
Release Late-TQ
Release P
Value
All regional complications 7.9% 14.8% .006
Complications that required
another operation* .3% 3.1%
.04
*Wound dehiscence, hematomas, and infections that
required drainage and / or debridement and knee stiffness
that required manipulation with pt under anesthesia.
Rama K, Apsingi S, Poovali S, Jetti A. Timing of tourniquet release in knee arthrop lasty. J Bone Joint Surg am, 2007; 89:699-705.
Rama et al, J Bone Joint Surg, 2007
10x rate of reoperations due to post op complications in
late versus early TQ release group!
Tourniquetless TKA
•Infection – antibiotic concentration, tissue
oxygen perfusion
•Blood loss
•Vascular Effects
–Arterial damage
•Return to OR
–DVT
•Multi-organ effects
–Pulmonary, hepatic, splenic
•Cognitive function
•Pain
•Muscle function / Rehab
Tourniquetless TKA
•Intraoperative (real time) control of
blood loss
•Decreased metabolic challenges
•Improved postoperative function
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Thank you
